RN Nurse Navigator

Blue Ridge Care; Winchester (VA); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus $10,000

Job summary

Blue Ridge Care is seeking a compassionate Registered Nurse (RN) to serve as a Nurse Navigator – Principal Care Management (PCM). You will provide comprehensive, patient-centered care coordination for individuals with high-risk, complex chronic conditions and intensive clinical oversight.

You will be the primary clinical contact for enrolled patients, creating proactive care plans and ensuring care is coordinated, compliant, and meaningful in collaboration with providers and interdisciplinary

Qualifications

• Current RN license required.
• 2–3 years clinical nursing experience in chronic disease management preferred.
• BSN preferred.
• Experience in PCM/CCM or Population Health is a plus.
• Certification in care coordination or chronic disease management preferred.

Responsibilities

• Identify and enroll eligible patients into PCM program.
• Develop individualized care plans aligned with guidelines and goals.
• Conduct monthly PCM interactions with CMS-compliant documentation.
• Monitor symptoms, labs, and clinical changes; intervene early.
• Provide medication education and lifestyle coaching.
• Coordinate referrals, testing, and follow-up with care team.
• Address barriers to care including transportation and social determinants.
• Track outcomes and participate in quality improvement.

Skills

Chronic disease mgmt

Care coordination

EMR documentation

Patient coaching

Clinical judgment

Education

BSN preferred

RN license

RN-BC in Care Coordination

Tools

EMR systems

Job description

$10,000 Sign-On Bonus – Join Blue Ridge Care Today!

Your neighbors need you. Your nursing skills can change lives.

Join Blue Ridge Care and become a Future Maker—where your compassion and clinical expertise help patients confidently manage complex chronic conditions and improve their quality of life every day.

Our mission is simple yet powerful: “Delivering extraordinary care to improve life’s journey.” As a mission-driven, not-for-profit healthcare system, we provide integrated services in hospice, serious illness care, PACE, community thrift shops, and grief support—serving our community with heart, hope, and respect.

About the Role

We’re seeking a compassionate Registered Nurse (RN) to serve as a Nurse Navigator – Principal Care Management (PCM). In this role, you will provide comprehensive, patient-centered care coordination for individuals living with a high-risk, complex chronic condition requiring intensive clinical oversight.

As the primary clinical contact for enrolled patients, you’ll create proactive, personalized care plans that improve outcomes, reduce fragmentation of care, and empower patients to better manage their health. You’ll collaborate closely with providers and interdisciplinary partners to ensure care is coordinated, compliant, and meaningful.

How You’ll Make a Difference

• Identify and enroll eligible patients into the PCM program and complete comprehensive initial assessments.

• Develop individualized, disease-specific care plans aligned with clinical guidelines and patient goals.

• Conduct monthly PCM interactions with accurate CMS-compliant time tracking and documentation.

• Monitor symptoms, treatment adherence, labs, and clinical changes—intervening early to prevent deterioration.

• Provide medication education, lifestyle coaching, and motivational support to improve self-management.

• Coordinate referrals, diagnostic testing, follow-up visits, and interdisciplinary communication.

• Address barriers to care including transportation, social determinants of health, and financial concerns.

• Track outcomes, engagement, and quality metrics to continuously improve chronic condition management.

• Participate in periodic call rotation and collaborate in quality improvement initiatives.

What You’ll Bring

• Current Registered Nurse (RN) license.

• Minimum 2–3 years of clinical nursing experience (chronic disease management preferred—cardiology, pulmonology, endocrinology, rheumatology, or similar specialties).

• Strong knowledge of chronic condition management and patient coaching strategies.

• Experience with care coordination and EMR documentation.

• Bachelor of Science in Nursing (BSN) preferred.

• Prior experience in Principal Care Management (PCM), Chronic Care Management (CCM), Case Management, or Population Health preferred.

• Certification in care coordination or chronic disease management (e.g., RN-BC in Care Coordination & Transition Management) preferred.

• Strong clinical judgment, organizational skills, and the ability to build meaningful relationships with patients and providers.

• A proactive, compassionate spirit ready to serve your community and improve life’s journey.